State Policies Expanding Access to Behavioral Health Care in Medicaid
Issue Brief
State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and District of Columbia on October 1.
“Mental disease” is an antiquated term used in the statute. It comprises “diseases listed as mental disorders in the International Classification of Diseases with the exception of mental retardation [sic], senility, and organic brain syndrome,” including the Diagnostic and Statistical Manual of Mental Disorders, and encompasses alcoholism and other chemical dependency syndromes. CMS State Medicaid Manual § 4309 (D), (E), https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html.
KFF analysis of 2020 National Survey on Drug Use and Health (NSDUH). Estimates from the 2020 NSDUH should not be compared to prior years due to methodological changes.
KFF’s 21st annual budget survey surveyed Medicaid officials in all 50 states and DC about certain policies in place in state fiscal year (FY) 2021 and policy changes implemented or planned for FY 2022, which began on July 1, 2021 for most states. State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and District of Columbia on October 1.
Delaware, Minnesota, New Mexico, and Rhode Island did not respond to the 2021 survey. In some instances, we used publicly available data or prior years’ survey responses to obtain information for these states.
In addition to the SUD benefit expansions counted here, eight states (District of Columbia, Georgia, New Mexico, North Dakota, Oklahoma, Rhode Island, South Carolina, and Tennessee) reported new or expanded medication-assisted treatment (MAT) benefits in FY 2021. Federally required changes, such as coverage of MAT (including all FDA-approved drugs, counseling services, and behavioral therapy) as mandated by the SUPPORT Act, are not counted as positive or negative benefit changes for purposes of the budget survey. Future research may explore state experiences with these federally required MAT benefit expansions.
The eight states are: California, Connecticut, Iowa, Massachusetts, Michigan, Montana, Nevada, and West Virginia.
Section 223 of the Protecting Access to Medicare Act of 2014 established a demonstration program to improve community mental health services by funding planning grants for states to implement CCBHCs. The proposed BBBA would expand this program by providing additional planning grant funding.
In addition to setting requirements for CCBHCs, the 2014 Act directed CMS to issue guidance on a prospective payment system for mental health services furnished by CCBHCs to account for the total cost of comprehensive services they provide. The CCBHC demonstration aims to improve the availability and quality of ambulatory behavioral health services and to provide coordinated care across behavioral and physical health. CCBHCs provide nine types of services: crisis mental health services; screening, assessment, and diagnosis; patient-centered treatment planning; outpatient mental health and substance use services; outpatient clinic primary care screening and monitoring; targeted case management; psychiatric rehabilitation; peer support and counselor services and family supports; and intensive, community-based mental health care for members of the armed forces and veterans. CCBHCs may partner with designated collaborating organizations to provide some of these services.
42 CFR § 438.3 (e)(2)(iv).
There may be small population enrollment variations to the classifications of “always carved-in” and “always carved-out.” For example: North Carolina launched its “Standard” acute managed care program July 1, 2021 with most mental health services carved in, with an exception to mandatory enrollment for individuals with SMI or SED for specialty outpatient mental health services. Missouri carves out inpatient mental health services for the foster care population, while these services are carved in for all other managed care populations.
Three of the 30 states answering “yes” did not provide examples of approved in lieu of services (Arkansas, Utah, and Virginia) and Maryland answered “yes” but noted that no in lieu of services were currently defined.
The 2016 Medicaid Managed Care Final Rule allows states, under the authority for health plans to cover services “in lieu of” those available under the Medicaid state plan, to receive federal matching funds for capitation payments on behalf of nonelderly adults who receive inpatient psychiatric or SUD treatment or crisis residential services in an IMD for no more than 15 days during a given month. KFF’s 2019 budget survey explicitly asked states to indicate if using Medicaid managed care ILOS for enrollees receiving inpatient treatment in an IMD as detailed in the 2016 final rule; 35 of 41 MCO states reported using this authority in FY 2019 and/or FY 2020 (see Table 9).
For example, Texas reported working with CMS and stakeholders to institute several additional behavioral health ILOS. California reported that while it does not permit MCOs to cover ILOS as of July 1, 2021, starting January 1, 2022, it would authorize a new menu of ILOS as part of its CalAIM initiative, including sobering centers.
Appendices
KFF analysis of 2020 National Survey on Drug Use and Health (NSDUH). Estimates from the 2020 NSDUH should not be compared to prior years due to methodological changes.
States must offer ABPs to individuals newly eligible under the Affordable Care Act (ACA) Medicaid expansion and may choose to offer ABPs to most other Medicaid adults as well.